Davies v. First Reliance Standard Life Insurance Co.

Presently
pending before the Court are the parties' cross motions
for summary judgment. (Docs. 13, 19). Plaintiff Kristen Ann
Davies initiated this action under the Employee Retirement
Income Security Act of 1974, 29 U.S.C. § 1001, et.
seq. (“ERISA”), alleging that Defendant
First Reliance Standard Life Insurance Company (“First
Reliance”) arbitrarily and capriciously denied her
ongoing disability benefits. (Doc. 1). Plaintiff filed a
motion for summary judgment on October 14, 2016, along with a
brief in support. (Docs. 13, 14). First Reliance filed a
brief in opposition on November 28, 2016 (Doc. 16), including
argument in support of its own cross motion for summary
judgment that was formally filed later. (Doc. 19). Plaintiff
filed a brief in opposition to First Reliance's cross
motion on December 14, 2016. (Doc. 17). First Reliance filed
a brief in reply on January 4, 2017. (Doc. 23). While
Plaintiff did not file a brief in reply with regard to her
own motion for summary judgment, the time for filing has long
passed (See Local Rule 7.7) and she inherently
included reply argument in her opposition to First
Reliance's motion. Therefore, the motions are fully
briefed and ripe for our review. For the following reasons,
we shall grant summary judgment in favor of First Reliance.

I.
BACKGROUND

First
Reliance sold a group long term disability insurance policy,
LTD 118674 (the “Policy”), to Plaintiff's
employer, Forest Laboratories, Inc. (Doc. 13, ¶ 4).
Prior to claiming disability, Plaintiff worked for Forest
Laboratories, Inc. as a Pharmaceutical Detailer, which is a
light level occupation. (Doc. 15, p. 20, ¶ 2). The
relationship between First Reliance, Forest Laboratories,
Inc., and Plaintiff is governed by ERISA. (Doc. 13, at ¶
5).

The
Policy includes the following provision: “[t]he claims
review fiduciary has the discretionary authority to interpret
the Plan and the insurance policy to determine eligibility
for benefits.” (Id., at ¶ 9). First
Reliance granted itself discretion as the “claims
review fiduciary” and “is solely responsible for
claim handling, claim reviews, and claim decisions.”
(Id., at ¶¶ 9-10). The Policy defines
“Total Disability” as follows:

“‘Totally Disabled' and ‘Total
Disability' mean, that as a result of an Injury or
Sickness:

(1) during the Elimination Period and for the first 24 months
for which a Monthly Benefit is payable, an Insured cannot
perform the material duties of his/her Regular Occupation;

(a) ‘Partially Disabled' and ‘Partial
Disability' mean that as a result of an Injury or
Sickness an Insured is capable of performing the material
duties of his/her Regular Occupation on a part-time basis or
some of the material duties on a fulltime basis. An Insured
who is Partially Disabled will be considered Totally
Disabled, except during the Elimination Period;

(b) ‘Residual Disability' means being Partially
Disabled during the Elimination Period. Residual Disability
will be considered a Total Disability; and

(2) after a Monthly Benefit has been paid for 24 months, an
Insured cannot perform the material duties of Any Occupation.
We consider the Insured Totally Disabled if due to an Injury
or Sickness he or she is capable of only performing the
material duties on a part-time basis or part of the material
duties on a Full-time basis.”

(AR0010).[1] The Policy also includes the
following limitation, which we will refer to as the
“Mental/Nervous limitation”:

“MENTAL OR NERVOUS DISORDERS: Monthly
Benefits for Total Disability caused by or contributed to by
mental or nervous disorders will not be payable beyond an
aggregate lifetime maximum duration of twenty-four (24)
months unless the Insured is in a Hospital or Institution at
the end of the twenty-four (24) month period. The Monthly
Benefit will be payable while so confined, but not beyond the
Maximum Duration of Benefits. . .

Mental
or Nervous Disorders are defined to include disorders which
are diagnosed to include a condition such as:

(1) bipolar disorder (manic depressive syndrome);

(2) schizophrenia;

(3) delusional (paranoid) disorders;

(4) psychotic disorders;

(5) depressive ...

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